Clinical Practice Guidelines for the management of locally advanced ...

For non-metastatic disease there were two studies 11, 57, 58 , one (supported by industry) compared
bicalutamide with castration, and the other 21 (not supported by industry) compared two LHRH
agonists with cyproterone acetate and clinical monitoring. Both studies showed that castration was
associated with poorer sexual function than anti-androgen monotherapy. In the bicalutamide study,
physical capacity as measured with the Cleary instrument was improved with bicalutamide, however,
there were no significant differences in the other eight domains.
Only one study 21, 59 had patients randomised to a non-treatment arm in a clinical environment in which
commencement of androgen deprivation was triggered increasingly by a raised PSA for patients not
having treatment with curative intent. The numbers in this study are small but they reported a
significant increase in emotional distress for the non-treatment arm (p = 0.002) with increased sexual
dysfunction at one year for all three treatment arms, particularly for goserelin (p < 0.001).
In the adjuvant setting, long-term quality-of-life impacts related to therapy, when dealing with the
‘chance of having cancer’, present another paradigm. These studies reported radiotherapy adverse
events rather than quality of life outcomes using validated instruments.
Evidence summary Level References
Using validated quality of life assessment questionnaires:
For non-metastatic prostate cancer there was evidence that
medical or surgical castration is associated with poorer sexual
function when compared with non-steroidal anti-androgen
monotherapy.
II 11, 57,
58,21, 59
Since all quality-of-life studies examined report overall group findings, they should be regarded in a
general sense when supporting individual patients in their treatment choices. This relates in particular
to timing the commencement of androgen deprivation because of the absence of a clear and
significant overall survival benefit with early versus later introduction of ADT.
Recommendation
Toxicities should be considered in the context of what is important to each individual patient,
as for some patients impairment of sexual function may have a significant impact on their
quality of life and overall adjustment, as well as affecting adversely those close to them.
Grade C
Intermittent or continuous ADT
See section 5.1.6
3.1.2 Radiotherapy
Definitive external beam radiotherapy techniques for locally advanced disease
There are nine randomised controlled trials comparing various definitive external beam radiotherapy
techniques that include men with locally advanced disease. These studies investigate:
limited versus extended field radiotherapy (three trials)
various dose regimens (four trials), and
conformal versus conventional techniques (two trials).
25
Locally advanced disease